In a year when the United States has been riddled with bad news, confusion, and even threats of fines and incarceration (1) surrounding the use of influenza vaccines, the last thing you may be interested in thinking about is instituting a comprehensive inpatient influenza vaccination initiative. Despite the chaos, it is important to remember that, on average, 36,000 (2) people die and 226,000 (3) people are hospitalized annually from influenza, or “the flu,” and its complications. Additionally, a significant proportion of patients hospitalized will have co-morbid illness or be old enough to be considered in the highest risk category for complications of flu (4). Hospitalists are poised to act centrally in improving vaccination rates given the intensity of their patient contact and their expertise in developing best-practices-based systems.
What follows is a step-wise plan to help you begin an inpatient influenza vaccination initiative at your institution. Clearly, elements of this plan will need to be modified based on institutional structure and preference.
1. Define the problem locally. It is important to identify if any inpatient vaccination systems are already in place for any other vaccination (e.g., pneumococcal vaccination for splenectomy patients; tetanus for trauma patients, etc). If such a system already exists, review its successes and see if any of them may be borrowed for the influenza plan. Also determine if influenza vaccines have ever (even in a random, sptty fashion) been given out on your institution’s inpatient service. Understanding this history will help you address the issues of the “culture” of the institution.
2. Talk with your administration about making influenza vaccination a quality goal. One of the barriers ahead may be the mindset that vaccinations should only live in the world of outpatient physicians. By obtaining “buyin” from administration (e.g., the Chief Medical Officer), you may have some additional resources made available to you, and you may also be able to leverage the weight of the administration in recruiting help for the program. Remember, the 2005 Disease-Specific Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) state that it is important to “develop and implement a protocol for administration and documentation of the flu vaccine.” (5)
3. Identify key players and meet with them. This plan cannot be sustained successfully as a one-person show. Ideally, you should create an influenza vaccination committee that has representatives of all the inpatient services (medicine, family medicine, surgery, obstetrics and gynecology, and pediatrics), as well as nursing leadership, infection control, pharmacy, information technology (for computerized order entry systems), and quality assurance. In academic institutions, you might also consider including a house officer and/or medical student. The initial meeting should review your findings with #1 and #2 above, as well as assessing this committee’s concerns about implementing an inpatient vaccination scheme. You should plan to initiate committee activities at least two to three months in advance of the anticipated availability of the vaccine.
4. Create a culture of vaccination. Vaccines are often not on the radar screen of most inpatient physicians as they deal with the more acute reasons for hospitalization. It is therefore important to begin introducing a culture change, demonstrating the importance of vaccinations to your staff, and shifting the prevalent mindset towards active engagement with your vaccination program. Identifying foreseeable problems and developing action plans will assist this process. Some issues may include:
- Physician and nurse attitudes and education about influenza and the vaccine (e.g., dispelling flu shot rumors, educating staff on the low risk of re-vaccinating a patient already vaccinated previously this season, explaining the lack of requirements for written informed consent for flu vaccination, encouraging health care workers to get flu shots themselves (6), etc.)
- Reminder systems for physicians to reinforce the need to vaccinate (posters, screen savers, emails, buttons)
- Communication with primary care physicians about patients who have been vaccinated
- Patient misconceptions about the vaccine’s side effects